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Home My WebLink About018-1094-06-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ` INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.Od A)(m)). 'ermit Holder's Name: City Village X Township LeQue Builders LLC Hammond Townshi ~ST BM Elev: Insp. BM Elev: BM Des iption: TANK INFORMATION EL ATION DATA TYPE MANUFACTURER CAPACITY Septic / Z Dosing ~ ,/~ - 1 ~- , Aeration ~~---- Holding TANK SETBACK INFORMATION TANK TO ~~/~ WELL- BLDG. Ven-!Intake ROAD Septic ~3/ `/D ,t / (/ ~~ r d Dosing Aeration Holding -~` ~' PUMP/SIPHON INFORMATION L~ Y -1-ltll,cJ Manufacturer Demand GPM Model Numbe ITDH (Litt (Friction Loss ~_ m Hid ITDH Ft Forcemain SOIL ABSORPTION SYSTEM o~`I County: $t. CroiX Sanitary Permit No: 453439 0 State Plan ID No: Parcel Tax No: 018-1094-06-000 Section/Town/Range/Map No: 17.29.17.746 STATION BS HI FS ELEV. Benchmark ~ I / ~ ~, v ~,, ~ ~` 3 Alt. BM_ Bldg. Sewer 3a3 _8~ 99, St/ t Inlet o ? ~1. S S t Outlet a 8 ~. ~ Dt Inlet ~- Dt Bottom _~ `_~ 1 Header/M/ManSIG`Q ~-(' Y-}'S L,3 S~ (a Dist. Pipe `Tr o~ G ~ 12 • ~ fo. ~ S Bot. System ~~ r~.. s 9~~~ Fina^ I 1 /.0 9p. 3 St Cover / ,~ i ° 3 SJ G (` d'~ (/ /r+., D ~ BED/TRENCH DIMENSIONS Width / Leng~ ~ I // No. Of Trenches PIT IMENSIONS No. Of Pits Inside Dia. Liquid Depth 3 ! SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufac ) ~ ~ INFORMATION HAMBER O ~~ / Type Of System:. h r ~~ i ~;y(µ~~ Model Number: 7 ~ ~ ~' ~ J DISTRIBUTION SYSTEM ~~ „(per ~ ,%e~a .l/%~ ~6 -'-~ ~ /r-~Cl~i~r~vc .l~/ Header/Mpnifold ~ li Distribution 7 ~ v ,~ Pipe(s)/ ~, '1 ~ x Hole Siz _ x Hole Spacing ~ Length Dia Length ! d Dia acing ~ SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Only 61~ 3 -~ 1 vt -EvO~--, ~l Vent to Air Intake 3 S~ ~' Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Tren enter 2 l ~ Bedlrrench Edges Topsoil Yes ~ No [~ Yes it ~ No COMMENTS: (Include code~iscrepencies, persons present, etc.) Inspection #1: I ~/ [ ~ / 6 j.~ Inspection #2: / / Location: 987 166th St U~ikaewn W /1 4 NE~4 17 T29N R17W Prairie Run L t 6 (-~\ Parcel No: 17.29.17.746 1.) Alt BM Description = ~ (~ ~G< <~'~j -~jfc. ~~~,~,Q~ ~ ~j ~ -~j ...~ 2.) Bldg sewer length =~~ r v J ~ ~~ ~6 L, - amount of cover = ~ rs L~"n`~~~~/~~"~~ _-~ Plan revision Required, ~Z Yes ` ~, Nor%o~ ~ --- - --- ,; - _ _ ---- -- - ----- -'--i I---i - ---,~I Use other side for additional ~ ~ information. ~i ~ ~ ~~~~ ~ ' -_ _ - -~~s!r-/!~ iv-~- ~ ~i _ ~, -~ - - SBD-6710 (R.3/97) Date Insepctor's Signa ur Cert. No. ~ _ __ _,: _~ _ __ _ _ M ~ - _ __ .__ ~c o 42 `~ - ~ ~ ~~ ~ ~ ~ ~ :~ ~ ~ l Q ^ ~~ _ •`~ ~ __1 ~ ~ ~ ~ ~~b~ r ~ ~ ~ ~ ~ ~~ ~ •~ Q ~ ~ Q _ ~ ,~'~ ''__ _ \ ~ _~_ ~ _-y _ __ _~ __~ _ _ _ _ _ \ ` o\ _ _ ~ \ a __ _ _ --- ~ -- -- -, tl ~_~ - ~ ~ __ -- - - _ - -- ~~~ _ ~~ ~'~' _ Ss ~' ~ ~ ~~ ~~ _~ _. > ~ _ ~~ mac( ~~~ ~ r~ u~ ~~ ~ ~ ~ C~ ~ ~ --~ ~ ~~ ~ 30 ~~~F ~~~ ~ ~ ~~ ~~ ~ ~- ~ ~' ~ \-'. ~ 9~r ?~p .~ ~` $ ~~ ~~ o ~ ~ ~ ~~ fl i ~ ~ n ~~ z `\ 3 ~ ~a ~~ ~ ,N ~ -~ Q ~~ 0 --~ ,~ o ~. ~~~ .~ ' N ~\ ,~ ~ ~~ ~ 0 ~ _ ~~ ~_ n~ 9~ q~~\ o ~ , `~ ,~ \, y \ I ,, `~~ ~~ ~ -~ ~~ ~ ~ ~` ~, ~~ ~ ~~ ~ ~~~ ~~ ~~ . /~ ~ ~~ `~ ~ ,. ~ ~ ~~~ ,~ ~- ~c \ Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ` ISC®~~~`,~ Madison, WY 53707 = 7162 Sanitary Permit umber (to be filled in by Co.) (608)266-3151 3 Department of Commerce Sanitary Permit Application state Plan I.D. Number pers9nal infrirrttOtidn you prpvide Wis. Adm. Code In accord with Comm 83.21 , , may be used for secondary purposes Privacy Law, s15.04(1)(m)' - roject Address (if different than mailing address) L Application Information -Please Print All Information ~,~/ Property Owner's Name ~ c # ~ Lot # Block # r-- Property Owner's Mailing Address ' Property Location Section ~~ ~~ '~` ~ ~ City, tate Zip Code Pho ~ ,~ p ~ (circle e) ~~ N; R~~ ot~~ pe o Building (check all that apply) ~ ~ S rMt T . y lli D N f d Qg Subdivision Name C~ioi-iqumoor we ng - umber-o Be rooms 1 or 2 Family /Commercial -Describe Use ^ P bli u c ^ State Owned -Describe Use ^City_ illage .®Township of III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) v g- p -Q(_QQp , `~' ~-New System ^ Replacement System ^ TreatmenUHoldin Tank Re lacement Onl g p Y ^ Other Modification to Existin S stem g Y B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a 1 2 1< ® Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter eaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Information: ~ - ~ Design Flow (gpd) Design Soil Application Rate(gpdsf} Dispersal Area Required (sf} Dispersal Area Proposed f) yytem evation ~~ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units WI ~ (~ A _ ~~ ' oncrete Constructed Glass New Existing t~~ ~,~ Tanks Tanks ' Septic or Holding Tank - Aerobic Treatment Unit Dosing Chamber VII. Reapo sibility Statement- I, the undersigned assume responsibility for installation of the POWTS shown on the attached plans. Plumber's am (Prin~ Plum er's ~ ure t MP/MPRS Number Business Phone Number ~ - ~= 5 Plumber s Address (Street, City, State, Zip ode ~~ ` a . VIII. Coun /De artment Use Onl ~iP.pproved ^ Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuing gent Signature (No Stamps) r ` ^ Owner Given Reason for Denial Surchazge Fee) ~~ ~_ IX. Conditions of Approval/Reasons forDisapproval ~, J~A.I to t V~+tM• ~ ~ Stotit ' ~_ SYSTEftn OWNER: 1 Septic tank, effluent filter and ~''~ S~~- ~ dispersal cell must all be serviced /maintained as per management plan provided by plumber. tf > A 1' '~ /'_ . - n ~ d~2L~tl~C ~ I 2. All setback requirements must be maintained / ~ V as per applicable code/ordinances. -~?.t>~y~, at/~~. ,~~6( ~'!! Attach complete plans (to the County only) for the system on er not ss than 812 11 itches in sizr- ~( SBD-6398. (R. 01/03) .~ , ~. r~~• Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT n ~ ~.Qj ~6 ZS L' Page ~ of J County ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must r include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to neares t road. P/ease print all information. Re 'wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1 ) (m)). , ~ 3 Property Owner t ~ Property Location ~ 1 ~ 1 t Govt. Lot NUJ 1/4 NFL 1/4 S ~ i- T 2 ~ N R E (or~ Property Owner's Mailing Address C ~ Lot # Block # S .Name or CSM# // l~ ~ ~ ~ / ~ City State Zip Code Phone Number ^ City ^ Village [~ Town Nearest Road ~ v~vt.~ w ( S ~a i S (7/S) 7 9 G - ~ ~3 ~a v~ m.a v~aQ /l>G t~- ~.c . I~ [~ New Construction Use: [~ Residential /Number of bedrooms ~ Code derived design flow rate y.Sali~ O G GPD ^ Replacement 7~ ^ Public or commercial -Describe: Parent material / ~ ~ ~ Flood Plain elevation if applicadle~.. ~• N//•T'~~,, ft. General comments S ~ s~rn~ e(.c u. ~ P Q ~' 3 ~ Go ""-ei- ~1 Sr• ~ ° and recommendations: ~~, 6~~U, )"gyp y ~*~,c Law-c,~ r/~3o ~" ~. y'~ `t1 ~( . ^ Boring `,~ ~t ?r <' ~ iF'~. ZCD / Boring # ,~r ~~{lry~ ~' `6TPit Ground surface elev. •~U ft. Depth to limiting factor.-~~_y~•'`~~a' -' E .,;`^ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary 'R` GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~`' ~;;,,,e. ` *Eff#1 *Eff#2 ~ o- ~~ i - m cS ~ v . 5 2 - --~ ~.S r c _ Z 3 - mS - - . ~ .d ~.~.~, rZ ~ ~ 3. z 9. Z ~ ^ Boring # ^ Boring ~- Pit Ground surface elev. ~q.3U ft. Depth to limiting factor ~~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I - I ~ Z ~~ t ~-~ - to ~/ `-' c-5 ~ - / . 2 3 ~ ~ ~ I _ ..- • fS•~ ~.(~ * Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L ., .~ .~ CST Name (Please Print) Si nature CST Number h m e .~------ Address Date Evaluation Conducted Telephone Number Lt13 ~''~I. -~ t 4025 /J Z 8- -~ 2y7- yoo SBD-8330 (R07/00; • ~~ ti y .s r~ Property Owner {,-lo~l~~ kl l'~ S Parcel ID # Page ~ of J © Boring # ^ Boring Pit Ground surface elev. gf~,3a ft. Depth to limiting factor 5~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 I -I ~-- 5~ 2 cS v .5 . 2 14~- I r - c.S c. --- . ~'1 1- Z I r - ~5 1 _ - . -7 Z ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munse{I Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) ,. .., ~. ., PAGE 3 OF~ ~;A_ME ~~-~ ~ ~'n S T OT# ~ LFGAL DESCRIPTIONNuJ IaNF' ~ ,S [ ~- T ZR ,N,R, [ ~ E(orl~ ~CALE: 1"= ~6 '"r BM 1 ELEVATION j0(, • y ._._---- BM 1 DESCRIPTION ~o P o -~ ~1_ ~ L~~ ; P ~- BM 2 ELEVATION qq. so _---- BM 2 DESCRIPTION ~o p a ~. ) ~~ Pvc. P i'p ~ / SYSTEM ELEVATION -~o p ~j ~'.3o j~w.e,!- `f ff .U d ALTERNATE ELEVATION ~ (~ `j ~ (DO Lower 9 ~• 30 CONTOUR ELEVATION ~S! 3 Q d- ~'~ 3 0 ~% ~, C. \~ 4~~ z ~'~ ~.^ 3'% ~ 1 - `}_ "_" 3~ ~~ 3v ., ~~•3d ~,,/~~ ~ . ~' SIGNATURE f - .~~~ DATE / ~-~Z -o/ FILE,INFORMATII Owner Permit ~ _~ ~ POWTS~OWNER'S MANUAL & MANAGEMENT_PLAI1>,;~r,~,,:; Pagp~,,,of~ P~~.~;r c~;"..,~ 1rr ~ SYSTEM SPECIFICATIONS' ~ ~ • ~,; • OESIf3N PARAMETERS Number of Bedrooms O NA Number of Public Facility, Units ~A Estimated, flaw leverage) al/da Design flow (peak(, (Estimated x 1.61 al/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) S30 mglL Bloch®mical Oxygen Demand IBOD,1 5220 mg/L ^ NA Total Suspended Svlida ~TSS) 6160 mg/I. Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (@OD`I s30 mg/L Total Suspended Solids (TSS- s30 mg/L O NA Fecal Coliform (geometric mean) a10' cfu/100m1 Maximum Effluent Particle Size Y~ in dia. ^ NA Other ^ NA *Valuea typical for domoatio WeeteWator and peptic tsnk effluent. MAINTENANCE SCHEDULE Septic Tank capacity re; ~ ~ ~•: , ~~•' al O Nt Soptio-Tank~ManufapturKr~• ;>}~•` q N; Effluent FilterMaanufaofurer`~'`• "~ `~ ~ •~'` ' 0 N~. Effluent Filter Model ~ <~ ^ Nti Pump Tank Capacity al ,~ NH Pump Tank Manufacturer..:. «- . ~ s . ~ ~" NA Pump Manufaoturer'~~'"~~°'-`•' t''' ~`'~t`~ ~`~~' '~" ~ ~ ,Sl NA Pump Modal ~ 'r: ;~,, rti ~ , ~i NA Pretreatment Unit '~• `*'~ ~ ^-: Q Sand/Gravel Filter ^ Pset Filter O Mechanical Aeration O Wetland , 0 Dlsinfaction ;,,.:, Q,Qtb ; j~ N~. Diaporsal Collis) O NA ~11n-Ground (gravity) "' ` O in-Ground (preawrized) O At-Grade - • •,Q Mound `~ ^ Drip-Line O Other; Qther ^ NA then s;~~. ~-~ ~ ,.. O NA Other. ~ O NA .~~. rj;; ;~, a Servico Event Service Frequency Inspect condition of tank(s) At least once every: ,, ~ ion 8 (~,«; . (M~In 3 yparsl O NA Pump out contents of tank(s) ~ When combined sludgo and scum equals one•thirtl,,(Ya) of tank VplWtle ~, O NA Inspect dispersal cell(s) At least once every: mont Isl " ~ ~ earls) (Maximum, 3 years) ^ NA Clean effluent filter At least once every: ^ month(s) . -131 earls- (~ NA Inspect pump, pump controls & alarm At least once avory; ^ month(s) O ear a) ~ NA Flush laterals and pressure test At least once every: ~ month a arE .A~t~;za•t~ •~~'~*•~ •~~ ^ earls( ®NA Other: At least once every: ^ month(s) •' :~ ^ ear18) ~ NA Other: 4 O NA MAINTENANCE INSTRUCTIONS a~x••- Inspectiona of tanks and dispersal cells shall ba made by an Individual carrying one of the following Names or .certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tangy inspections must include a visual Inspection of the tanklsl to identify any missing or broken hardware, identify any sacks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the grour-d surface The dispersal cell(s) shall be visually Inspected to check the effluent levels in the observation pipOs and to check for-any pondin~. of effluent on the ground surface. The ponding of effluent on the ground surface may Indicate a failing condition and requites tnc: immediate notification of tho local regulatory authority. - --. -- -~:.' = When the combined accumulation of sludge and scum In any tank oquais ono-third IY~-, oi' more of the tank volume, the entire contents of the tank shall bo romgvod by a 8eptago Servicing Operator end diaposod of in eccord)anae witch c1h(ap~tt~eyra}r NR 113, Wiavon;in Administrativo Code. _ a, _ _ . ,, . .., , All othor services, includl~i~ but not limited to tho oerviclnq of effluont filters, mechanlcaY or proaaurised o0mponente, pretreatmon; ur'iits, wnd arty servi~;Irtg at Intervals of 512 months, snail be pdrformsd by a cartifiod POW~'S fuialntairwr. A service report shall be provided to the local regulatory authority within 10 days of completion of an a~n~,igo evortt. ,, ;t;;~~. . OMW 141ot) ~, °.~. ~ ~,,~~~ Pegs ~ of START UP AND OPERATIONz' ` ~ ~ . • for new oonstruotion, prior to use of the P4WTS ~2heck !re~acmen! tenkfa6 for the aresenoe of painting aroduots or other chemicals that may Impede the treatment process and/or damage the dispersal cellls). If high concentrations are detected have the oontents of the tankls) removed by a septage servicing operator prior to u ~. System start up shelf not occur when soil conditions are frozen at the Infiltrative surface. During power outapss pump anke-may. fill above. Hormel hlghwaeer Isvslr When power Is restored thixoasa wastewater will ba discharged to the dispersal celllal in one large doss, overloading the osllls) and may rewlt in tl» backup or wrfao~ discharge of effluent. To avoid this situation have the oontents of the pump tank removed by a Septage Servking Operator prior. to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump' controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 16 feet down slope of any mound or at•grade soil absorption area. , , ,, , Reduction or~Niminatton of the following from the wastewater stream may Improve the performance and prolong the Ilfe of the POWTS; antibbtios; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floes; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides;, meat scrape; medications; .oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ;3ANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely. abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanka• and pits shall be disconnected and the abandoned pipe openings sealed,,; • The oontents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the Vold space filled with soil, gravel or another inert solid material. :ONTINGENCY PLAN ' if the POWT$ fails and .cannot be repaired the .following measures have been, or must be taken, to provido a code compliant replacement system: • _ . •: ~..,; ,.,, ,:-,. ,, ~; • A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result In the need for s new Boll and site evaluation to establish a suitable. replacement eras. Rapleoement systems muss comply with the rules in effect at that timo, ^ A suitable replacement area is not available due to setback and/or soil limitations, Barring advances In POWTS technology a hokfing tank.may be Installed as a leaf resort to replace the failed POWT8. °~•-• - - ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a .holding tank may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconatruotiona of such systems must comply with the rules in affect at that time. r .!A,.. < WARNING ». - .: _ . __ SEPTIC, PUMP AND OTHER TREbYN1ENt tANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A 8EPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES, DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. DDITIONAL COMMENTS $;"~ .~ ., ~-bWT8 INSTALLS 1 , ~ ~ POWT8 MAINTAINER .~, Name ~ Name Phone Phone ....: . ~PTAGE SER~i~~NG OPERATOR ihUMPER ~ LOCAL REGULATORY AUTHOR Name Name Phone Phone s document wee drafted in oomplianc• with chapter Comm 83.2212)Ib111)Idl&If) and 83,64(11, 12- & 131, Wisconsin Administrative Code. 07/19/2004 09:49 FA% 1 71:i 247 9098 13ELISLE E%CAVATING ~'C CKUJX GUUN'I'1' 51:1''1'lC "1'AN1~ A•1.~1N,'1'GNA~NCIr AG1tLLMEN7' AND OWNCRSHIAICERTIFICATION FORM Owner/Iiu; ct fs~ L ~k.•t_ ~it~ lc ~ ~ f Nl:tilirt~ :a,~iJrc~~ r 6 /..~U>l ~~ • /~' ----~-- / -~L- / , • (Verification required from Planning bepsrrment for naw conatn+cton) :~ City/S t;~t ~ C{ ~'~-/''~-. ~- ~,~ Parcel dentification Numbrr ~ t ~ - f ° " ©6" °.~ . ~~ 1'rvprrty Lut;atiun ~ %, ~, ~'/a, Sec. _f~,, "„N-R,,,,~,~W, Town of - .,,,; Subdivision ~ may!': L- 24•/ Lt,t ~ , ~~• C~rtifit:d ~urvey l14ap ~ ~_ ,~, Volume Page # Warratxty Uced +~ ~696tf'~ _-,,, Volume 2.623 ,Page #• ?O3 Spec hausc LJ ~~cs do Lot lines idcntiiiabte yes l7 no S 'ST~'N_ i 11.1.4I~N'1'~KN:~NCE lrnprupcr uac :+nd ma intenanceof your septic System Gould result in its premature failtue to handle wpatea. Proper A1giAtCaepee consists vE pumping uu, the septic tank suety three yeah or svvaer, if needed by s liceneod pumper. W4-et you put iAto the system canrffect the t'unta+un of the septic tank as a treatmeat'ag: in the waste diepos4l system. '1'hc fnuf~rn~• oa•nc- agrcrs to submit to St. Croix ;.oning Department a ecrtificvtion form, eignod by the owner and by • tttnstcr t,+w-u~~,, ,uw ncyn,:ui i;fuu7bcr, rrstrtt:trtl plumber ur a ,iccnsetl pumper veril'yittg tlWt (1) the On-Site waslewatcrdispOS+tl t;ystctu is in pruf,r, ~.,1.,:,•.,t,nl; Cu,~Jn,un amt/a+ (~) al'Icr insprctinn and pumping (il'ntcesstrry), tbw septic tank is less than I13 full OCsludge. awe, the undat•,tgneci hxve read the above requirements and rrgrce to maintain the private sewage disposal syskm with the sttaltdards set fothlt, herein, as set by the Department of Commerce aad ht: Depactntoot of Natural Resources, State oP Wiscoaslu. CatRiPieation stating that your septic system has been maitttoincd must be c amploted and returned to the St. Croix County Zoning Offioe within 30 day u!` lht: three yerr c~ptrariot~ de . 7 /..,..,,,,,! S(G RJr ~~1~ ~1'1'LI~~AN1' DA'1'B OWNt?k CF,~TIFYCA't'ION 1 (We) ccrtiiy that 811 statements un this forrti era trt• to the best of my (our) knowledge. I (we) tun (rue) the owner(s) of tttc ru c,Tl• .Ics~i ~b«i abi,vc, by virtue of u w•rranty decd rK t:ortlcd in {tt:gistt:r of Dtads Office. • ~ ~3 ~ Sl N URk. VF AI'1'Llt~A1~('f DATE "•"~ Any inl'urmauan tat is rnis•represcntt:dmay result it the sanituy permit being rovoked by th0 ZOging i>'epartrrtettt, •••••• •• lnt;lutlr Frith Utis ,+pplieatiuu: a slantpt:d warranty dead Irom the Regiscar of Deeds office a copy UC the certified sur~ey m•p if reference i9 made in rho wartanty deed U 2623P 203 STATE BAR OF WISCONSIN FORM 1 - 1998 Doctunent Number WARRANTY DEED ~ 018-1094-04-000 Parcel Identification Number (PIN) ade between Robert Lind and Denise Lind, Grantor(s), and eQue Builders, LC, Grantee. for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property"): SEE ATTACHED EXHIBIT A Recording Area 7 6 9 6 8 8 KATHLEEN H_ MALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 07/23/2001 10:30AM YARRAHTY DEED EXDPT • REC FEE: 13.00 TRANS FEE: 132.00 COPY FEE: CC FEE: PAGES: 2 Together with all appurtenant rights, title and interests. Name and Return Address: Gr or w ants that the title to the Property is good, indefeasible in Land Title, Inc., fee sim a and ee d ear of encumbrances ex t 1900 Silver Lake Road, Suite 200 p New Brighton, MN 55112 Dated is 2004. ~~~ ~ ~~~-~ (SEAL) J/,~~! II~i(, ~~`~'I~~ (SEAL) Robert Lind Denise Lind s (SEAL) (SEAL) r AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Minnesota authenticated this 2004 s TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Gregory A. Booth, Attorney at Law 1900 Silver Lake Road, Suite 200 New Brighton, MN 55112 (Signatures may be authenticated or acknowledged. Both are not necessary.) •Names of persons signing in any capacity must be typed or printed below their signature. SS. COUNTY. Washington \~ Personally came before me this ~TFt ~`f OF ~t-t_l_~/ 2004, the above named Robert Lind and Denise Lind Grantor, to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. Notary Public, State of MI NNESD't'Fc tDttl L YYEMHi • nor~av rll~lc~+w-i~sor>. ~, , 2623P 20y EXHIBIT A Lot 6, rairie Run, Town of Hammond, St. Croix County, Wisconsin ~- .,, O w ~ ~ ~ "`°'' U o o~ ~• V y N h ~~ ~ O N W ... M ~ N ~ tp ~ tp Ih tp Q ~ ~ ~ ~ w ~ M J ~ ~ ~~ rn goT' 38' 15' - E - z ... ^228.47' coo ' " ~ 5 j 3~ ~~"480'-- e - --... Q33~ a AREA __._.. -- ~ S00°39 ' 03"E g 927. 12' ' h 227.89' 227. ' A I NAGS 7 N . ~' W •.........'' N ~ !' 3~--9 ~ ~ ' +35 7.88' 129.89' . ,, °•,, - W W a ~ ~ ~ ~ w rn w W ~~ ~ ''- ~ ti d ~ ~ •.. ~ ~D N ~ . ~ N N a~ ~•~. M ,~ ~`O m h o "' N ~ _~ w • ^ U w O sF ^ Q h O O '.. ~ ... ~ ,.. o ~ ? ••- ,ti~ . `. N rn • d1 .Ilr •t 9 "'`~. ° 2S 313. ~` \~. •~B •``-~2 ~~ 215.58':. o'' . N` `'.~;?~r •,t+d~ .Er tid s sy~ a .~ ® ® ~' ---------- 58.57'------ -- E 3 14. 33' `O - - O ~ - ~_d ~' ~ . W 314.44' ~ \_ \~ `~~~~ ~ cv~~ ~ x - -- 115.82' -•- --- _, •~ ~ ~~. t LINE •''`•~••. ` ` ~ ~ ~-t- W •.~ `` ` `` ~~ H ` ` g ®``~. `~® ~ o d ti 00 0 op a U o \lu \~ /~~\ M '~ G~ O N fn d' ~ / ~d~ ~ ~ ti ~ 'h 2 ~~ ~~ 632. 00' 335. 03' ' ' 66 OQ 97. 73 N01 ° 01 ' 49" W v1`. ~ ~ w ~ti`~~ ' ~' ~ o h v • ' ~: ~~ ~ N .~ N eF~3' 87, .E 0~l'38 520 ,,,~ ~ •_ ~ N w ~... v ~~ ~~ ~ ~ 3 ~ `~ Q' 1 ~ M ~ I: M ~ ~ . ~. ~~ ~>~ i / y 520. 05' W ~ ~ V d ~ Q ~ O ~ ~ •~.~ N N N-S QUARTER SECT W~ N01 ° 01 ' 49" W 192. 04' (TO Sh w °' ~. ? 5255. 63' (TO SOUTH QUARTER ~''